Gender
Male
Female

Race
Caucasian
African American
Asian
Hispanic/Latino/a
Other

Highest Education Level
Grade School
High School
Some College
College Degree (BA, BS)
Graduate School (MD, PhD, JD)

1. I have a diagnosis of following type of cancer (eg,breast, prostate, lung, throat etc.):
   -- Please Select -- BONE CANCERS —Ewing's Sarcoma —Osteosarcoma —Rhabdomyosarcoma and Other Soft-Tissue Sarcomas BRAIN TUMORS BREAST CANCER ENDOCRINE SYSTEM CANCERS —Adrenal Cancer —Pancreatic Cancer —Parathyroid Cancer —Pituitary Cancer —Thyroid Cancer GASTROINTESTINAL CANCERS —Anal Cancer —Colorectal Cancer —Esophageal Cancer —Gallbladder Cancer —Gastric Cancer —Liver Cancer (Hepatoma) —Pancreatic Cancer —Small Intestine Cancers GYNECOLOGIC CANCERS —Cervical Cancer —Endometrial and Uterine Cancer —Fallopian Tube Cancer —Gestational Trophoblastic Disease and Choriocarcinoma —Ovarian Cancer —Vaginal Cancer —Vulvar Cancer HEAD AND NECK CANCERS —Laryngeal Cancer —Oropharyngeal Cancers —Parathyroid Cancer —Thyroid Cancer LEUKEMIA —Acute Lymphocytic Leukemia (ALL) —Acute Myelogenous Leukemia (AML) —Chronic Lymphocytic Leukemia (CLL) —Chronic Myelogenous Leukemia (CML) —Hairy Cell Leukemia —Myeloproliferative Disorders LUNG CANCERS —Mesothelioma —Non-Small Cell Lung Cancer —Small-Cell Lung Cancer LYMPHOMAS —AIDS-related Lymphoma —Cutaneous T-Cell Lymphoma/Mucosis Fungoides —Hodgkin's Disease —Non-Hodgkin's Disease METASTASES MISCELLANEOUS/OTHER DISEASES —Ataxia-Telangiectasia —Carcinoma of Unknown Primary —Li-Fraumeni Syndrome —Thymoma MYELOMA PENILE CANCER PROSTATE CANCER SARCOMA —Ewing's Sarcoma —Osteosarcoma —Rhabdomyosarcoma and Other Soft-Tissue Sarcomas SKIN CANCER —Cutaneous T-Cell Lymphoma/Mycosis Fungoides —Kaposi's Sarcoma —Melanoma TESTICULAR CANCER THYROID CANCER URINARY TRACT CANCERS —Bladder Cancer —Kidney Cancer —Urethral Cancer
   
   
2. I am currently getting or did get radiation therapy for my cancer.
   Yes
   No
   
   
3. I am currently getting or did get chemotherapy for my cancer.
   Yes
   No
   
   
4. I had surgery or am scheduled to have surgery for my cancer.
   Yes
   No
   
   
5. I am currently enrolled in a clinical cancer trial or experimental study.
   Yes
   No
   
   
6. After I was diagnosed with cancer, I started using or taking: (check all that apply)
   Vitamin supplements, including anti-oxidants (eg,vitamin C, E, etc)
   Herbal and/or botanical supplements (eg,saw palmetto, ginseng, etc)
   Soy foods, soy drinks, or other phytoestrogen-containing products
   Omega-3 Fatty Acid supplements, like fish oil or cod liver
   Medicinal skin balms/salves
   Acupuncture Therapy
   Massage Therapy
   Other
   Nothing